7 nutritional disorders

8/11/2019 7 Nutritional Disorders

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7 Nutritional Disorders

Nutrient and Energy Requirements in Humans

Recommended dietary allowance (RDA)

1. Optimal dietary intake of nutrients that under ordinary conditions will keep the general population

in good health

2. Varies with se! age! "ody weight! diet! and physiologic status

Nutrient and Energy Requirements in Humans


1. Optimal dietary intake of nutrients that under ordinary conditions will keep the general populationin good health



1. Optimal dietary intake of nutrients that under ordinary conditions will keep the general populationin good health


Daily energy ependiture (D##)1. $actors influencing D##

a. %asal meta"olic rate (%&R)". 'hermic effect of foodc. hysical actiity

2. %asal meta"olic rate (%&R)a. Accounts for *+, of D##". #nergy consumption inoled in normal "ody functions

#amples-cardiac function! maintaining ion pumps


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c. %ody weight is the most important factor determining %&R.d. 'hyroid function alters the %&R.

%&R is increased or decreased in hyperthyroidism and hypothyroidism!

respectiely.. 'hermic effect of foods

o #nergy used in digestion! a"sorption! and distri"ution of nutrients2. Degree of physical actiity

o Varies with the leel of physical actiity

Dietary Fuels

/ar"ohydrates

1. 0lucose

a. tored primarily as glycogen in lier and muscle". R%/s use only glucose for energy.c. /omplete oidation produces kcal3g.

2. #n4ymatic digestiona. %egins in the mouth (amylase)". ancreatic amylase

5n chronic pancreatitis! car"ohydrates are notmala"sor"ed due to predigestion

"y saliary amylase.c. %rush "order intestinal en4ymes (disaccharidases)

ii 6ydroly4e lactose! maltose! and sucrose

iii

Disaccharidases produce glucose! galactose! and fructose.

/ar"ohydrates

1. 0lucosea. tored primarily as glycogen in lier and muscle". R%/s use only glucose for energy.c. /omplete oidation produces kcal3g.

2. #n4ymatic digestiona. %egins in the mouth (amylase)". ancreatic amylase

5n chronic pancreatitis! car"ohydrates are notmala"sor"ed due to predigestion

"y saliary amylase.c. %rush "order intestinal en4ymes (disaccharidases)

ii 6ydroly4e lactose! maltose! and sucrose

iii Disaccharidases produce glucose! galactose! and fructose


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roteinspage 121

page 122

1. Amino acids are su"strates for gluconeogenesis2. Digestion

a. %egins in the stomach (pepsin and acid)". ancreatic proteases (e.g.! trypsin) and peptidases release amino acids.

. /omplete oidation produces kcal3g.

$ats

1. 'riglyceridesa. &a7or dietary lipids". &a7or source of energy for cells exceptR%/s and "rain

2. #ssential fatty acidsa. 8inolenic acid is cardioprotectie.". 8inoleic acid is re9uired for synthesis of arachidonic acid.c. Deficiency of essential fatty acids

i. caly dermatitisii. oor wound healing! hair loss

. Digestion of dietary triglyceridea. Occurs primarily in the small intestine

i. 6ydroly4ed "y pancreatic lipaseii. %ile salts3acid re9uired for rea"sorptioniii. ackaged into chylomicrons! which enter the "lood

". /omplete oidation produces :kcal3g.

Protein-Energy Malnutrition (PEM)

;washiorkor

1. athogenesisa. 5nade9uate protein intake". Ade9uate caloric intake consisting mainly of car"ohydratesc. rotein in lier and other organs (i.e.! isceral protein) is decreased.d. &uscle protein (i.e.! somatic protein) is relatiely unchanged.

2. /linical findings left)a. itting edema and ascites

/aused "y hypoal"uminemia and loss of plasma oncotic pressure". $atty lier

ii /aused "y decreased synthesis of apolipoproteins

iii Apolipoprotein %-1++ is re9uired for secretion and assem"ly of ery low density

lipoproteins (V8D8s) in the lier.". Diarrhea

/aused "y loss of the "rush "order en4ymes and parasitic infections


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". Anemia and defects in cell-mediated immunity (/&5)

;washiorkor1. athogenesis

a. 5nade9uate protein intake". Ade9uate caloric intake consisting mainly of car"ohydrates

c. rotein in lier and other organs (i.e.! isceral protein) is decreased.d. &uscle protein (i.e.! somatic protein) is relatiely unchanged.

2. /linical findingsa. itting edema and ascites

/aused "y hypoal"uminemia and loss of plasma oncotic pressure

". $atty lier

ii /aused "y decreased synthesis of apolipoproteins

iii Apolipoprotein %-1++ is re9uired for secretion and assem"ly of ery low density

lipoproteins (V8D8s) in the lier.". Diarrhea

/aused "y loss of the "rush "order en4ymes and parasitic infections". Anemia and defects in cell-mediated immunity (/&5)

&arasmus

1. athogenesisa. Dietary deficiency of "oth protein and calories". Decrease in somatic protein

2. /linical findingsa. #treme muscle wasting (


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c. 5ncreased lanugo (fine! downy hair)d. 5ncreased hormones associated with stress (e.g.! cortisol! growth hormone)

Anoreia nerosa1. athogenesis

a. elf-induced staration leading to #&

". Distorted "ody image2. /linical findings

a. econdary amenorrheai. Decreased gonadotropin-releasing hormone

/aused "y loss of "ody fat and weight

ii. Decreased serum gonadotropins produces hypoestrinism.". Osteoporosis

i. /aused "y hypoestrinismii. Decreased osteo"lastic actiity and increased osteoclastic actiity

c. 5ncreased lanugo (fine! downy hair)d. 5ncreased hormones associated with stress (e.g.! cortisol! growth hormone)

%ulimia nerosapage 12

page 12

1. athogenesiso %inging with self-induced omiting

2. /linical findings

a. /omplications of omiting

i. Acid in7ury to tooth enamelii. 6ypokalemia and meta"olic alkalosis

b. Ventricular arrhythmia is the most common cause of death.

O"esitypage 12

page 12=

1. %ody mass inde (%&5) +kg3m2(normal> 1?.=-2.:kg3m2)a. %&5 @ weight (kg)3height (m2)". Other factors than "ody weight

i. #cess fat in the waist and flanks is more important than an ecess in the thighsand "uttocks.

ii. #cess isceral fat in the a"dominal caity has greater significance than ecess

su"cutaneous fat.2. athogenesis

a. 0enetic factors account for =+, to ?+, of cases.

#amples-defects in the leptin gene! syndrome (o"esity! hypertension!dia"etes)

". Ac9uired causes


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i. #ndocrine disorders-hypothyroidism! /ushing syndromeii. 6ypothalamic lesions! menopause

". 8eptini. 6ormone is secreted "y adipose tissue that maintains energy "alance.ii. 8eptin increases when adipose stores are ade9uate.

Decreases food intake

5ncreases energy ependiture (stimulates B-oidation of fatty acids)iii. 8eptin decreases when adipose stores are inade9uate.

5ncreases food intake

Decreases energy ependiture (inhi"its B-oidation of fatty acids)

i. O"esity may "e due to seeral factors> Resistance to leptin effects

&utations resulting in inhi"ition of leptin release

. /linical findings

Table 7-! "lini#al Findings $sso#iated %it& Obesity"lini#al Finding "omments

/ancer 5ncreased incidence of estrogen-related cancers (e.g.! endometrial! "reast) "ecause ofincreased aromati4ation of androgens to estrogens in adipose tissue

/holelithiasis 5ncreased incidence of cholecystitis and cholesterol stonesC "ile is supersaturated withcholesterol

Dia"etes mellitus! type 2 5ncreased adipose down-regulates insulin receptor synthesis6yperinsulinemia increases adipose storeseight reduction up-regulates insulin receptor synthesis

6epatomegaly $atty change accompanied "y lier cell in7ury and repair "y fi"rosis

6ypertension 6yperinsulinemia increases sodium retention! leading to increase in plasma olume8eft entricular hypertrophy and stroke complicate hypertension

6ypertriglyceridemia 6ypertriglyceridemia decreases serum high-density lipoprotein leels! increasing risk ofcoronary artery disease

5ncreased low-densitylipoprotein leels

6ypercholesterolemia predisposes to coronary artery disease

O"structie sleep apnea eight of adipose tissue compresses upper airways causing respiratory acidosis andhypoemiaotential for deeloping cor pulmonale (pulmonary hypertension and right entricularhypertrophy)

Osteoarthritis Degeneratie arthritis in weight-"earing 7oints (e.g.! femoral heads)

Fat-'oluble itamins

Vitamins A! D! #! and ; are fat solu"le.

VitaminA

An ecess of B-carotenes in the diet causes the skin to turn yellow! "ut unlike in7aundice! the sclera remains white. B-/arotenes also hae antioidant actiity(neutrali4e free radicals).

1. Retinol


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a. Deried from dietary B-carotenes and retinol esters". &ain transport and storage form of itamin A

2. Retinala. roduct of the oidation of retinol". /omponent of the isual pigment rhodopsin

. $unctions of itamin A

a. Eormal ision in reduced light". otentiating differentiation of mucus-secreting epitheliumc. timulating the immune systemd. 0rowth and reproduction

. /linical uses of itamin Aa. 'reatment of acne (e.g.! isotretinoin)". 'reatment of acute promyelocytic leukemia

=. /auses of deficiencya. Diets lacking sufficient yellow and green egeta"les". $at mala"sorption (e.g.! celiac disease)

*. /auses of toicitya. /onsumption of polar "ear lier". &egadoses of itamin A

c. 'reatment with isotretinoin

F. /linical findings in itamin A deficiency and toicity

Table 7-! Fat-'oluble itamins* "lini#al Findings in De+i#ien#y and To,i#ity

itamin E++e#ts o+ De+i#ien#y E++e#ts o+ To,i#ity

A 5mpaired night ision! "lindness (s9uamous metaplasiaof corneal epithelium)$ollicular hyperkeratosis (loss of se"aceous glandfunction)! pneumonia! growth retardation! renal calculi

apilledema and sei4ures (due to an increase inintracranial pressure)! hepatitis! "one pain (due toperiosteal proliferation)

D athologic fractures! ecess osteoid! "ow legs/hildren> ricketsC craniota"es (soft skull "ones)C rachiticrosary (defectie minerali4ation and oergrowth ofepiphyseal cartilage in ri"s)

Adults> osteomalacia/ontinuous muscle contraction (tetany)

6ypercalcemia with metastatic calcification! renalcalculi

# 6emolytic anemia (damage to R%/ mem"rane)eripheral neuropathy! degeneration of posteriorcolumn (poor 7oint sensation) and spinocere"ellar tract(ataia)

Decreased synthesis of itamin ;-dependentprocoagulant factorsC synergistic effect with warfarinanticoagulation

; Eew"orns> hemorrhagic disease of new"orn (/E"leeding! ecchymoses)

Adults> gastrointestinal "leeding! ecchymosesCprolonged prothrom"in time and partial throm"oplastintime

6emolytic anemia and 7aundice in new"orns ifmother receies ecess itamin ;

/E! central nerous system.

Vitamin Dpage 12F

page 12?

1. &eta"olism


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a. reformed itamin D in the diet consists of cholecalciferol (fish) and ergocalciferol(plants).

". #ndogenous synthesis of itamin D in the skin occurs "y photoconersion of F-dehydrocholesterol ia sunlight.

c. Rea"sorption occurs in the small intestine.d. 8ier hydroylation to 2=-hydroyitamin D (2=-O6-D) occurs in the cytochrome -=+

system.e. ;idney hydroylation "y 1-G-hydroylase produces 1!2=-(O6)2-D (actie form of itamin

D).f. Vitamin D increases rea"sorption of calcium and phosphorus from the intestine and

calcium from the distal renal tu"ules.2. $unctions

a. &aintenance of serum calcium and phosphorus". Re9uired for minerali4ation of epiphyseal cartilage and osteoid matri

i. Receptor located on osteo"lastsii. timulates release of alkaline phosphataseiii. Alkaline phosphatase dephosphorylates pyrophosphate! which normally inhi"its

"one minerali4ationc. timulates macrophage stem cell conersion into osteoclasts

. /auses of deficiencya. Renal failure

Decrease in 1-G-hydroylation". 5nade9uate eposure to sunlight

Decreased synthesis from F-dehydrocholesterolc. $at mala"sorption

Decreased rea"sorption of itamin Dd. /hronic lier disease

Decreased synthesis of 2=-(O6)-De. #n4yme induction of the cytochrome -=+ en4yme system (e.g.! alcohol)

5ncreased meta"olism of precursors of 2=-(O6)-Dii &egadoses may cause toicity.

ii /linical findings in itamin D deficiency and toicity (see

Vitamin #

1. eres as an antioidanta. rotects cell mem"ranes from lipid peroidation from free radicals". reents oidation of low-density lipoprotein

2. Deficiency is uncommona. $at mala"sorption in children with cystic fi"rosis". A"etalipoproteinemia

. &egadoses may cause toicity.

4. /linical findings in itamin # deficiency and toicity


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Vitamin ;

1. Deried from endogenous "acteria and green egeta"les2. Actiated "y the lier microsomal en4yme epoide reductase

o Anticoagulant effect of coumarin deriaties results from the inhi"ition of epoide

reductase.. $unction

a. H-/ar"oylates glutamate residues in itamin ;-dependent procoagulants

i. rocoagulants include factors 55 (prothrom"in)! V55! 5! ! protein /! and protein .ii. rocoagulants are nonfunctional.

b. H-/ar"oylation allows itamin ;-dependent procoagulants to "ind to calcium in fi"rin clot

formation.2. /auses of deficiency

a. Ise of "road-spectrum anti"iotics

Destroy "acterial synthesis of itamin ;ii Eew"orns

i. 8ack "acterial coloni4ation of the "owelii. &ust receie itamin ; at "irth

reents hemorrhagic disease of the new"orn

%reast milk is deficient in itamin ;.

b. /oumarin deriaties

5nhi"it epoide reductase actiation of itamin ;ii $at mala"sorption

Decreased intestinal rea"sorption of itamin ;2. 'oicity caused "y ecessie intake of itamin ; is uncommon.

. /linical findings in itamin ; deficiency and toicity

ater-'oluble itamins

'hiamine (itamin %1)

Table 7-.! ater-'oluble itamins* "lini#al Findings in De+i#ien#y

itamin E++e#ts o+ De+i#ien#y

'hiamine(itamin %1)

Dry "eri"eri> peripheral neuropathy (demyelination)ernickeJs syndrome> ataia! confusion! nystagmus! mamillary "ody hemorrhage;orsakoffJs syndrome> antegrade or retrograde amnesiaC demyelination in lim"ic systemet "eri"eri> congestie cardiomyopathy with "ientricular failure

Ri"oflain(itamin %2)

/orneal neoasculari4ation! glossitis! cheilosis (cracked lips)! angular stomatitis (fissuring at anglesof mouth)

Eiacin (itamin%)

ellagra> diarrhea! dermatitis (hyperpigmentation in sun-eposed areas)! dementia

yridoine(itamin %*)

idero"lastic anemia (microcytic anemia with ringed sidero"lasts)! conulsions! peripheralneuropathy


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/o"alamin(itamin %12)

&egalo"lastic anemia! neurologic disease (posterior column and lateral corticospinal tractdemyelination)! glossitis

$olic acid &egalo"lastic anemia! with noneurologic disease (unlike itamin %12)! glossitis

%iotin Dermatitis! alopecia! lactic acidosis

Ascor"ic acid(itamin /)

eak capillaries and enules! skin ecchymoses! perifollicular hemorrhage (ring of hemorrhagearound hair follicles)! hemarthrosis! "leeding gums! anemia (com"ined iron and folate deficiency)8oosened teeth! glossitis! poor wound healing

1. $unctiona. /ofactor in "iochemical reactions that produce adenosine triphosphate (A')". #ample-pyruate dehydrogenase-cataly4ed conersion of pyruate to acetyl /oA

2. /auses of deficiencya. /hronic alcoholism (in the Inited tates)". Diet of nonenriched rice (in deeloping countries)

. /linical findings in thiamine deficiency

o igns and symptoms mainly result from A' deficiency.

'hiamine (itamin %1)

Table 7-.! ater-'oluble itamins* "lini#al Findings in De+i#ien#y

itamin E++e#ts o+ De+i#ien#y

'hiamine(itamin %1)

Dry "eri"eri> peripheral neuropathy (demyelination)ernickeJs syndrome> ataia! confusion! nystagmus! mamillary "ody hemorrhage;orsakoffJs syndrome> antegrade or retrograde amnesiaC demyelination in lim"ic systemet "eri"eri> congestie cardiomyopathy with "ientricular failure

Ri"oflain(itamin %2)

/orneal neoasculari4ation! glossitis! cheilosis (cracked lips)! angular stomatitis (fissuring at anglesof mouth)

Eiacin (itamin%)

ellagra> diarrhea! dermatitis (hyperpigmentation in sun-eposed areas)! dementia

yridoine(itamin %*)

idero"lastic anemia (microcytic anemia with ringed sidero"lasts)! conulsions! peripheralneuropathy

/o"alamin(itamin %12)

&egalo"lastic anemia! neurologic disease (posterior column and lateral corticospinal tractdemyelination)! glossitis

$olic acid &egalo"lastic anemia! with noneurologic disease (unlike itamin %12)! glossitis

%iotin Dermatitis! alopecia! lactic acidosis

Ascor"ic acid(itamin /)

eak capillaries and enules! skin ecchymoses! perifollicular hemorrhage (ring of hemorrhagearound hair follicles)! hemarthrosis! "leeding gums! anemia (com"ined iron and folate deficiency)8oosened teeth! glossitis! poor wound healing

1. $unctiona. /ofactor in "iochemical reactions that produce adenosine triphosphate (A')". #ample-pyruate dehydrogenase-cataly4ed conersion of pyruate to acetyl /oA

2. /auses of deficiencya. /hronic alcoholism (in the Inited tates)". Diet of nonenriched rice (in deeloping countries)

. /linical findings in thiamine deficiency

o igns and symptoms mainly result from A' deficiency.


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Ri"oflain (itamin %2)

1. Actie forms include flain adenine dinucleotide ($AD) and flain mononucleotide ($&E).2. Deficiency is caused "y seere malnourishment.

. /linical findings in ri"oflain deficiency

Eiacin (itamin %! nicotinic acid)page 12:

page 1+

1. $unctionsa. Actie forms of niacin

i. Oidi4ed nicotinamide adenine dinucleotide (EADK)ii. Oidi4ed nicotinamide adenine dinucleotide phosphate (EADK)

". EADKand EADKare cofactors in oidation-reduction reactions.2. /auses of deficiency (pellagra)

a. Diets deficient in niacin". Deficiency of tryptophan

i. 'ryptophan is used to synthesi4e niacinii. /auses of tryptophan deficiency

Diets deficient in tryptophan

6artnup disease

5n"orn error of meta"olism with ina"ility to rea"sor" tryptophan in

the small "owel and kidneys /arcinoid syndrome

'ryptophan is used up in synthesi4ing serotonin.. /linical findings in niacin deficiency (see. #cessie intake of niacin

a. 8eads to flushing caused "y asodilation

Aderse effect of nicotinic acid! a lipid-lowering drug

". 5ntrahepatic cholestasis

yridoine (itamin %*)1. $unctions

o Re9uired for transamination! heme synthesis! and neurotransmitter synthesis

2. /auses of deficiency

a. 5sonia4id (used in treating tu"erculosis)

b. 0oat milk! chronic alcoholism


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2. /linical findings in pyridoine deficiency

/o"alamin (itamin %12) (see

1. resent only in animal products (eggs! meat! dairy products)2. Re9uires intrinsic factor for rea"sorption in the terminal ileum. $unctions

a. DEA synthesis". ropionate (odd-chain fatty acid) meta"olism

. /auses of deficiencya. trict egan diet". ernicious anemiac. 'erminal ileal disease (e.g.! /rohnJs disease)! "acterial oergrowth

5. /linical findings in itamin %12deficiency

$olic acidpage 1+

page 11

1. resent in most foods2. $unction

o DEA synthesis

. /auses of deficiency

a. Dietary deficiency

#lderly indiiduals! goat milk

b. Drugs Alcohol! methotreate! phenytoin! oral contracepties! trimethoprim! =-fluorouracil

c. &ala"sorption! oerutili4ation (e.g.! pregnancy)

2. /linical findings in folic acid deficiency

%iotin

1. $unctiona. /ofactor in car"oylase reactions". #ample-pyruate car"oylase-cataly4ed conersion of pyruate to oaloacetate

2. /auses of deficiencya. #ating raw eggs (aidin "inds "iotin)". 'aking anti"iotics

. /linical findings in "iotin deficiency

Ascor"ic acid (itamin /)


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1. $unctionsa. 6ydroylation of lysine and proline residues in collagen synthesis

i. Deficiency leads to collagen with reduced tensile strength.ii. 6ydroylation sites are anchors for cross-linking of G-chains.

". Antioidant actiity

Regenerates itamin # and reduces oidation of low-density lipoprotein". reents nitrosylation

i. 5nhi"its amides from com"ining with nitrites present in food preseratiesii. Eitrosamines and nitrosamides are carcinogens implicated in stomach cancer.

". Reduces nonheme iron (K alence) from plants to the ferrous (K2 alence) state forrea"sorption in the duodenum

Deficiency may produce iron deficiency (microcytic anemia).". ;eeps tetrahydrofolate ($6) in its reduced form

Deficiency may produce folate deficiency (macrocytic anemia).c. /ofactor in the conersion of dopamine to norepinephrine in catecholamine synthesis

ii /auses of deficiencya. Diets lacking fruits and egeta"les". /igarette smoking

ii /linical findings in itamin / deficiency (scury)

ii #cess intake (hyperitaminosis /) may lead to the formation of renal calculi composed of uric

acid.

Tra#e Elements

'race elements are micronutrients that are re9uired in the normal diet.

Lincpage 11

page 12

1. $unctionsa. /ofactor for metalloen4ymes (e.g.! collagenase in wound remodeling)". 0rowth and spermatogenesis in children

2. /auses of 4inc deficiencya. Alcoholism! dia"etes mellitus! chronic diarrhea". Acrodermatitis enteropathica

i. Autosomal recessie diseaseii. Dermatitis! growth retardation! decreased spermatogenesis! poor wound healing

. /linical findings in 4inc deficiency


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Table 7-/! Tra#e Metals* "lini#al Findings in De+i#ien#y

Tra#e Metal E++e#ts o+ De+i#ien#y

/hromium &eta"olic> impaired glucose tolerance! peripheral neuropathy

/opper %lood> microcytic anemia (cofactor in ferroidase)Vessels> aortic dissection (weak elastic tissue)

&eta"olic> poor wound healing (cofactor in lysyl oidase)$luoride 'eeth> dental caries

5odide 'hyroid> thyroid enlargement (goiter)! hypothyroidism

elenium &uscle> muscle pain and weakness! dilated (congestie) cardiomyopathy

Linc &eta"olic> poor wound healing (cofactor in collagenase)&outh> dysgeusia (cannot taste)! anosmia (cannot smell)! perioral rash/hildren> hypogonadism! growth retardation

/opper

page 12

page 1

1. $unctions as a cofactor>a. $erroidase ("inds iron to transferrin)". 8ysyl oidase (cross-linking of collagen and elastic tissue)c. 'yrosinase (melanin synthesis)

2. /opper deficiency

o &ost often due to total parenteral nutrition ('E)2. /linical findings in copper deficiency

3. /opper ecess! ilsonJs disease>

a. Autosomal recessie disease". Defect in eliminating copper into "ilec. Defect in synthesi4ing ceruloplasmin ("inding protein for copper)

d. /hronic lier disease! ;ayser-$leischer ring in cornea! "asal ganglia degeneration

5odine

1. $unctiono ynthesis of thyroid hormone

2. 5odine deficiencyo &ost often due to inade9uate intake of iodi4ed ta"le salt

. /linical findings in iodide deficiency


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/hromium

1. $unctionsa. /omponent of glucose tolerance factor (maintains a normal glucose)". /ofactor for insulin that facilitates "inding of glucose to adipose and muscle

2. /hromium deficiency

o &ost often due to 'E

2. /linical findings in chromium deficiency

elenium

1. /omponent of glutathione peroidaseo Antioidant that conerts peroide to water using reduced glutathione (06)

2. elenium deficiencyo &ost often due to 'E

. /linical findings in selenium deficiency

$luoride

1. $unctiono /omponent of calcium hydroyapatite in "one and teeth

2. $luoride deficiencyo &ost often due to inade9uate intake of fluoridated water

. $luoride ecess

a. /halky deposits on the teeth

b. /alcification of ligaments

c. 5ncreased risk for "one fractures

2. /linical findings in fluoride deficiency

7 nutritional disorders

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